How does GapCover work?

In the Australian health system, there are a few different ways in which in-hospital medical services are funded.

To begin with, the Medicare Benefit Schedule (MBS) lists all of the medical services subsidised by the Australian government through Medicare. These medical services include doctors’ services (eg. GPs and specialists), or diagnostic services (eg. blood tests, x-rays and ultrasounds provided by your pathologist and radiologist).

For each service listed in the MBS, the government has determined a set fee. Medibank pays benefits to Medibank health members towards their in-hospital medical services based on the MBS.

Doctors aren’t duty-bound to charge only the MBS fee for their services – they can choose to charge an amount above the MBS fee. This is where out-of-pocket costs can arise. But there are some scenarios where Medibank’s GapCover can help reduce your out-of-pocket medical expenses.^*

Scenario one:

If you receive in-hospital medical services for an MBS listed service (that is included in your Medibank hospital policy), and if your doctor charges no more than the MBS listed fee, then the cost will be covered by Medicare (75% of the MBS fee) and Medibank (25% of the MBS fee). This means that you won’t have an out of pocket expense for your in-hospital medical services.

Scenario two:

If your doctor decides to charge more than the MBS fee for your in-hospital medical treatment, you will be left with an out-of-pocket expense to pay after Medicare and Medibank have paid their portions. This is commonly referred to as the ‘gap’.

The good news is that Medibank has a scheme designed to help reduce your out-of-pocket expenses for in-hospital medical treatment, aptly named ‘GapCover’. If your doctor chooses to participate in GapCover and you have a Medibank hospital policy that includes GapCover,^# then Medibank may pay an additional benefit (ie. GapCover benefit) above the MBS fee.

If the GapCover benefit is sufficient to cover the whole ‘gap’ then you will not have an out of pocket expense. Please note that GapCover doesn’t cover all medical services, and doctors can choose whether or not to participate in GapCover for part, or all of your treatment.^*

Scenario three:

If your doctor chooses to participate in GapCover but the maximum GapCover benefit is not sufficient to cover the whole gap, then you will be charged an out-of-pocket expense. Provided your total out-of-pocket cost remains within $500 then GapCover is still able to be applied to help cover part of the gap.

Scenario four:

If your doctor charges a ‘gap’ that results in an out-of-pocket cost of more than $500, then GapCover is not able to be applied to help cover any of the gap. This unfavourable scenario results in the highest out-of-pocket expense as you will need to pay the whole gap amount yourself.

Similarly if your doctor chooses not to participate in GapCover, then you must pay the whole gap as an out-of-pocket cost.

While doctors don’t have to participate in GapCover, you can see from the above scenarios that it’s always worth asking the question to help you reduce your out-of-pocket expenses.

And remember, there may be several doctors involved in your procedure (eg. your primary specialist, assistants, anaesthetists, etc.) who will each be charging a fee for their service – ask each of your treating doctors for a breakdown of all the costs in writing. This is known as Informed Financial Consent.

By being a Medibank health member and choosing a doctor who chooses to participate in GapCover (and one who will treat you at a Medibank Members’ Choice hospital), your out-of-pocket expenses could be significantly reduced.^*

It’s important to note that out-of-pocket expenses may arise for costs associated with your hospital accommodation as well.

If you are anticipating a hospital admission, be sure to read our Going to hospital brochure, or give us a call on 132 331 so we can give you the info you need to help you minimise your out-of-pocket medical expenses, and maximise your potential for achieving better health.